Dynamics of serum α-fetoprotein in viral hepatitis C without hepatocellular carcinoma

A "Mix and Match" in Hemochromatosis-A Case Report and Literature Focus on the Liver

Hemochromatosis is a genetic disorder characterized by increased iron storage in various organs with progressive multisystemic damage. Despite the reports dating back to 1865, the diagnosis of hemochromatosis poses a challenge to clinicians due to its non-specific symptoms and indolent course causing significant delay in disease recognition. The key organ that is affected by iron overload is the liver, suffering from fibrosis, cirrhosis or hepatocellular carcinoma, complications that can be prevented via early diagnosis and treatment. This review aims to draw attention to the pitfalls in diagnosing hemochromatosis. We present a case with multiorgan complaints, abnormal iron markers and a consistent genetic result. We then examine the relevant literature and discuss hemochromatosis subtypes and liver involvement, including transplant outcome and treatment options. In summary, hemochromatosis remains difficult to diagnose due to its symptom heterogeneity and rarity; thus, further education for practitioners of all disciplines is useful in facilitating its early recognition and management.

The Management of Postoperative Cognitive Dysfunction in Cirrhotic Patients: An Overview of the Literature

Background and objectives: Postoperative cognitive dysfunction (POCD) represents a decreased cognitive performance in patients undergoing general anesthesia for major surgery. Since liver cirrhosis is associated with high mortality and morbidity rates, cirrhotic patients also assemble many risk factors for POCD. Therefore, preserving cognition after major surgery is a priority, especially in this group of patients. The purpose of this review is to summarize the current knowledge regarding the effectiveness of perioperative therapeutic strategies in terms of cognitive dysfunction reduction. Data Collection: Using medical search engines such as PubMed, Google Scholar, and Cochrane library, we analyzed articles on topics such as: POCD, perioperative management in patients with cirrhosis, hepatic encephalopathy, general anesthesia in patients with liver cirrhosis, depth of anesthesia, virtual reality in perioperative settings. We included 115 relevant original articles, reviews and meta-analyses, and other article types such as case reports, guidelines, editorials, and medical books. Results: According to the reviewed literature, the predictive capacity of the common clinical tools used to quantify cognitive dysfunction in cirrhotic settings is reduced in perioperative settings; however, novel neuropsychological tools could manage to better identify the subclinical forms of perioperative cognitive impairments in cirrhotic patients. Moreover, patients with preoperative hepatic encephalopathy could benefit from specific preventive strategies aimed to reduce the risk of further neurocognitive deterioration. Intraoperatively, the adequate monitoring of the anesthesia depth, appropriate anesthetics use, and an opioid-sparing technique have shown favorable results in terms of POCD. Early recovery after surgery (ERAS) protocols should be implemented in the postoperative setting. Other pharmacological strategies provided conflicting results in reducing POCD in cirrhotic patients. Conclusions: The perioperative management of the cognitive function of cirrhotic patients is challenging for anesthesia providers, with specific and targeted therapies for POCD still sparse. Therefore, the implementation of preventive strategies appears to remain the optimal attitude. Further research is needed for a better understanding of POCD, especially in cirrhotic patients.

Multimodal Treatment of Hepatocellular Carcinoma in Patients With Hepatitis C Virus Infection Treated With Direct-Acting Antivirals

Background: Direct-acting antivirals (DAAs) opened a new era in the management of hepatitis C virus (HCV)-associated liver disease. However, hepatic cancer screening should not be stopped after obtaining a sustained virologic response (SVR). Current guidelines offer several treatment options for hepatocellular carcinoma (HCC), mainly depending on its stage and the extent of liver disease, including tumor resection, liver transplantation (LT), radiofrequency ablation (RFA), transarterial chemoembolization (TACE), and systemic agents. This article provides an overview of treatment modalities for hepatocellular carcinoma and associated survival rates based on the experience of the Internal Medicine Center at Fundeni Clinical Institute while bringing into light previous medical research.

Methods: We included 59 patients with a personal history of hepatitis C virus infection, diagnosed with hepatocellular carcinoma at least one year after achieving a sustained virologic response through direct-acting antivirals. The albumin-bilirubin (ALBI) score and Barcelona Clinic Liver Cancer (BCLC) classification were assessed in each case, and all patients were treated accordingly. The subjects were monitored by liver function tests, tumor markers, blood cell count, coagulation profile, and imaging explorations. We investigated the Eastern Cooperative Oncology Group (ECOG) performance status, the response to applied treatments, and survival.

Results: Cirrhotic patients and multinodular tumor patterns were predominant. Most patients only experienced one therapeutic procedure, while the rest of the study group went through multiple treatment modalities (2-4), with a better outcome in terms of survival parameters. A large proportion presented with disease progression despite the therapeutic measures applied. A total of two liver transplants were performed, resulting in a 12-month disease-free period among these patients. The presence of diabetes mellitus (DM), multinodular disease, alpha-fetoprotein (AFP) over 300 ng/mL, and tumor dimension over 6 cm indicate poor overall survival. Both overall survival and progression-free survival were better in subjects who presented complete responses (CR) to HCC treatment. In patients undergoing a single intervention, the best overall survival was associated with surgical resection and RFA.

Conclusion: The multimodal treatment of hepatocellular carcinoma represents the best approach, in order to maintain patients on the waiting list for liver transplantation. In hepatitis C virus infection, viral clearance is important to obtain. At the same time, particular attention should be paid to liver cancer screening even after obtaining a sustained virologic response.

Correlation Between Serum Alpha-Fetoprotein and Tumour Size in Patients With Hepatocellular Carcinoma Treated With Direct-Acting Antivirals

Objectives: Since its first description, alpha-fetoprotein has become the most widely used marker for diagnosing and monitoring patients with hepatocellular carcinoma (HCC). This study aims to assess the correlation between serum levels of alpha-fetoprotein and tumour dimensions in patients diagnosed with HCC, that were previously treated with direct-acting antivirals for hepatitis C viral infection.

Materials and methods: We conducted a retrospective cohort study on 47 patients with a personal history of hepatitis C virus infection, who were diagnosed with different forms of HCC more than one year after achieving sustained virologic response after 12 weeks post-treatment. Patients were monitored by liver function tests, tumoral markers, blood cell count and coagulation profile and underwent imagistic explorations such as abdominal ultrasonography and, in selected cases, computerised tomography/magnetic resonance imaging. Tumour burden was assessed by both tumour burden score and seven-eleven criteria.

Results: The study mostly included cirrhotic patients, multinodular HCC being the predominant pattern. All patients had alpha-fetoprotein levels over 100 ng/ml, with values largely varying, in accordance with the tumour dimensions. Most patients had medium-range Tumour Burden Score, a variable that also correlated with nodule size.

Conclusions: The study found a significant correlation between serum alpha-fetoprotein and tumour size in patients with HCC. Alpha-fetoprotein also correlated well with Tumour Burden Score and remains a very important diagnostic and prognostic tool for patients with HCC.

Epigenetics in inflammatory liver diseases: A clinical perspective (Review)

Inflammatory liver diseases are, nowadays, multifactorial and wide-spread, thus having an important socio-economic impact. Although the therapeutic algorithms are well-known in hepatitis, regardless of etiology, strategies to identify inflammatory hepatic lesions in early stages and to develop new epigenetic therapies should be prioritized. The main entities of inflammatory liver disease are: alcoholic and non-alcoholic fatty liver disease, autoimmune hepatitis, viral hepatitis and Wilson disease. The main epigenetic processes include: DNA methylation/demethylation, which imply changes in DNA tertiary structure; post-translational histone covalent changes (methylation/demethylation, acetylation/deacetylation, ubiquitination), that cause DNA-histone instability; synthesis of small, non-coding RNA molecules, called microRNAs, that modulate translational potential of transcripts (mRNAs) and post-translational modification of polypeptide chains. Consequently, the epigenetic interactions aforementioned, play an important modulatory role in disease progression and response to conventional therapies The present review focused on the main epigenetic changes in inflammatory liver conditions, considering a new perspective: Epigenetic therapy. This approach is more than welcomed, taking into consideration that conventional therapeutic strategies are almost exhausted.